Record Keeping Guidelines Flashcards
What is the difference between guidelines and standards?
Guidelines are aspirational in intent, intended to facilitate the continued systematic development of the profession and to help facilitate a high level of practice by psychologists, not intended to be mandatory or exhaustive and may not be applicable to every professional situation, not definitive nor intended to take precedence over the judgment of psychologists.
Standards are mandatory and may be accompanied by an enforcement mechanism. These guidelines are intended to provide psychologists with a general framework for considering appropriate courses of action or practice in relation to record keeping.
Why do you keep records?
They benefit the client and the psychologist through documentation of treatment plans, services provided, and client progress. It documents the psychologist’s planning and implementation of and appropriate course of services, allowing the psychologist to monitor her work. They may be especially important when there are significant periods of time between contacts or when the client seeks services from another professional. They can help protect both client and psychologist in the event of legal or ethical proceedings. They are generally required for third-party reimbursement for psychological services.
What was the finding of COPPS on state laws and regulations regarding record-keeping?
(Committee on Professional Practice and Standards) found state laws and regulations related to record keeping to be vague and vary substantially across jurisdictions.
COPPS was then tasked with developing these “Record Keeping Guidelines.”
Who is responsible for the maintenance and retention of client records?
The psychologist who has started a professional relationship with that client (that the records are about).
What are the guidelines in updating client records?
Update active records to reflect professional services delivered to the client and changes in the client’s status.
When working with a child who displays various inappropriate behaviors, the father reports to you that the stress is too much and he has been staying out late at the bar and thinks he may need counseling. What do you record?
I should only record information germane to the purposes for the service provided. In this case, it would be appropriate to record that the father is experiencing high levels of stress due to the various inappropriate behaviors of the child. However, I should not include that he has been staying out late at the bar and thinks he may need counseling.
In reviewing progress notes with your staff, you see that a staff member wrote “The parents have not been consistent in implementing the prescribed procedures. I have talked with the parents about this numerous times and think they really don’t want to be involved with their child.” Is this appropriate? And what should you do?
This is not appropriate. I should tell the staff member that his or her subjective opinion of the parents is not appropriate to include in the progress notes. I would add an addendum noting that these were not the [views] of the company and that additional training will be delivered in how to write up progress reports, including what to put in and what to leave out.
You have set up a behavioral program and ask the parents how things went last week. The parents stated “Things are great, Eric had a good week.” Is this sufficient?
This is not sufficient. However, it is not the responsibility of the parents to determine how much and what type of information to provide. I can follow up by asking more specific questions. I got a vague answer to a vague question.
When a client requests that limited records of treatment be maintained, what should you do?
Consider whether treatment can be provided under this condition.
In cases of emergency or natural disaster (hurricane, school shooting, death of a student), psychologists may provide services. What is the guideline regarding client records?
The records that are created may be less substantial because of the situational demands. The psychologist may be guided by the oversight agency regarding necessary elements for the record. In some situations, no further intervention beyond the on-site contact may occur and, given the brevity and sheer number of services provided, highly detailed records may be impossible to construct even after the crisis.
In reviewing progress notes with your staff, you see that a staff member wrote “the parents have not been consistent in implementing the prescribed procedures. I have talked with the parents about this numerous times and think they really don’t want to be involved with their child.” You discuss this with the staff member who states that the day was stressful and wasn’t really paying attention when writing the progress notes and then states they will submit an amended progress note removing the last comment. What do you say to the staff person?
We cannot simply remove information once a record has been made.
As part of a child’s IEP, you provide individual services to increase community participation. The school is interested in how things are going and for the upcoming IEP meeting, the school psychologist has requested that you provide a summary of your work. You write up a summary including baseline and intervention data and send it to the school psychologist. Is this correct?
I should not share any client information with a third party without consent from the client. In this case, I would need to obtain consent from the child’s legal guardian [other term to use here?] before disclosing any information to the school psychologist.
When should you discuss record-keeping procedures?
In circumstances where it is anticipated that the client might want or need to know how records will be maintained, the informed consent process may include disclosure of the record keeping procedures. Psychologists are encouraged to inform clients about situations where the manner in which records are maintained may potentially affect the client in ways that may be unanticipated by the client. Clients should also be informed of the potential of unauthorized re-release once an authorized release is made to a third party.
Why is re-release of data an ethical concern?
When a psychologist releases client records, with proper authorization to do so, they may be further distributed without consent from the psychologist or the client.
e.g., after release in a litigation context, records may be placed on the public domain; sending records to another professional, whose handling of those records is then beyond the control of the psychologist who sent them
What are the guidelines related to maintenance of client records?
Keep paper records in a secure manner in safe locations where they may be protected from damage and destruction. Condensed records may be kept in a separate location so as to preserve a copy from natural and other disasters. E-records stored on magnetic and other e-media may require protection from damage. Psychologists may plan for archiving of e-data including file and system backups and off-site storage of data.
The psychologist strives to organize and maintain records to ensure their accuracy and to facilitate their use by the psychologist and others with legitimate access to them. Records should be systematically updated and logically organized (in a manner that allows for thoroughness and accuracy of records, as well as efficient retrieval, which both benefits the client and permits the psychologist to monitor ongoing care and intervention). This allows for continuity of care should the psychologist die or become disabled or should the client’s case be unexpectedly transferred to another professional.
